Tattoo Infections Tied to Premixed Ink

Action Points

Despite strict adherence to sanitary practices, a tattoo parlor in Rochester, N.Y., was the center of an outbreak of Mycobacterium chelonae skin and soft tissue infection.

Note that eighteen of the 19 patients were treated with appropriate antibiotics, and their condition improved.

Despite strict adherence to sanitary practices, a tattoo parlor in Rochester, N.Y., was the center of an outbreak of Mycobacterium chelonae skin and soft tissue infections, researchers reported.

The culprit? A sealed batch of supposedly sterile premixed ink, direct from the manufacturer, according to Byron Kennedy, MD, PhD, of the Monroe County Department of Public Health in Rochester, and colleagues.

In all, 19 people developed a persistent, raised, erythematous rash in the skin above the tattoo in the last 4 months of 2011, Kennedy and colleagues reported online in the New England Journal of Medicine.

The bacteria were isolated from 14 of the 19 patients and also from an unopened bottle of premixed ink, suggesting the source was in the manufacturing chain. The ink's maker issued a voluntary recall of the product.

Eighteen of the 19 patients were treated with appropriate antibiotics and their condition improved, the researchers added.

In a separate but overlapping report in Morbidity and Mortality Weekly Report, researchers reported an additional eight confirmed cases of tattoo-associated skin infection by nontuberculous mycobacteria picked up by nationwide surveillance, including:

Three confirmed and 24 possible cases of Mycobacterium abscessus infection, and two confirmed and two possible cases of M. chelonae infection, in separate clusters in Washington state

Two confirmed M. chelonae cases in Iowa, and one in Colorado

None of the M. chelonae isolates were similar to those found in New York, the CDC report said, and a variety of inks were used.

The Rochester outbreak is unusual for two reasons, Kennedy and colleagues wrote.

In the first place, M. chelonae, a rapidly growing form of nontuberculous mycobacteria, is an "uncommon" cause of skin infections, Kennedy and colleagues noted. The pathogen has also only rarely been associated with tattoo-related infections.

And in the second place, most cases of tattoo-related infection arise from unsanitary practices in the tattoo establishment, rather than premixed packages of ink.

The findings suggest that the increasing popularity of tattooing may lead to an underestimate of the incidence of nontuberculous mycobacterial infections, the researchers argued.

And they also suggest that local health department surveillance of tattoo parlors themselves may need to be supplemented by oversight of the inks that are used.

Indeed, in an accompanying perspective article in the journal, Pamela LeBlanc, MPH, and colleagues at the FDA's Center for Food Safety and Applied Nutrition in College Park, Md., said that the case has "raised questions about the adequacy of prevention efforts implemented at the tattoo-parlor level alone."

The agency is currently trying to define what measures should be taken to improve public health in regard to tattoos, LeBlanc and colleagues wrote.

The investigation started after a dermatologist reported a persistent granulomatous rash on the arm of a patient who had recently been tattooed, Kennedy and colleagues reported.

The researchers found that the tattoo artist was careful about hygiene, using sterile instruments, clean disposable gloves, and single-use containers for the ink, and about providing appropriate aftercare to the site.

The inks were neither diluted nor mixed at the parlor, and the ink was not contaminated with tap water at the facility.

Once the 19 patients were identified through epidemiological investigation, the researchers obtained biopsy specimens from 17. They found sparse lymphohistiocytic infiltrates in the upper dermis in 12 specimens, granulomas in 5, and acid-fast organisms in 2.

M. chelonae was isolated in 14 of the 17 specimens and confirmed by DNA sequencing, they reported. In addition, the M. chelonae isolated from the ink was identical on pulsed field gel electrophoresis to 11 of the clinical isolates.

Kennedy and colleagues cautioned that detailed records at the tattoo parlor were lacking, making assessment of the extent of the outbreak difficult.

The authors did not report any external sources of support for the study or any potential conflicts.

The perspective authors did not report any external support or any potential conflicts.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner